Stroke remains one of Malaysia’s leading causes of death and disability, with its overall burden continuing to rise. According to the Global Burden of Disease 2019 study, Malaysia recorded approximately 47,900 new stroke cases, while more than 440,000 Malaysians were living with stroke-related complications. [Cerebrovasc Dis Extra 2022;12:58–62]
Further, a clear and concerning shift is emerging, with stroke increasingly affecting younger adults in their 30s to 50s, said Associate Professor Dr Hoo Fan Kee, Consultant Neurologist and Internal Medicine Physician, Hospital Sultan Abdul Aziz Shah, Universiti Putra Malaysia, at the “Time is Brain: Rapid Action Against Acute Ishaemic Stroke” panel discussion recently. A substantial increase in stroke incidence was observed in those younger than 65 years, with the largest increase—more than 50 percent—reported among men and women aged 35–39 years. [Cerebrovasc Dis Extra 2022;12:58–62] Also, the Malaysian National Stroke Registry reported almost 14 percent of stroke cases occurred in individuals aged below 50 years from 2009 to 2016. [https://tinyurl.com/43r6n983]
He added that non-communicable diseases (NCDs) such as hypertension, diabetes, hyperlipidaemia, and obesity are becoming more prevalent among younger Malaysians. The National Health and Morbidity Survey 2023 reported almost 2.3 million adults in Malaysia live with at least three NCDs, thus increasing their risk for stroke. Hypertension is the most prevalent risk factor for stroke in Malaysia, affecting nearly 70 percent of individuals experiencing a first stroke. Furthermore, one in three Malaysian adults has hypertension. [https://tinyurl.com/yeyp7kyf, https://tinyurl.com/468dzy8r]
Other contributing risk factors for first-ever stroke include type 2 diabetes mellitus (41.4 percent), smoking (26.3 percent), hyperlipidaemia (24.4 percent), family history of stroke (5.8 percent), and ischaemic heart disease and atrial fibrillation (3.4 percent). [https://tinyurl.com/4ermvv5m] Metabolic syndrome, characterised by the clustering of obesity, elevated triglyceride levels, insulin resistance, and liver disease, is increasingly prevalent and may accelerate vascular damage, including among adults in their 30s.
Time is brain
In stroke management, “time is brain.” Rapid restoration of cerebral blood flow is essential to minimise neurological injury and optimise recovery. Depending on the stroke type, clinical presentation, and eligibility criteria, treatment options available at a stroke-ready hospital include intravenous (IV) thrombolysis, mechanical thrombectomy, blood pressure and glucose management, and antiplatelet therapy, said Hoo. “We must ensure treatments are administered rapidly, within the ‘golden window.’ For IV thrombolysis, the golden window is within 4.5 hours of symptom onset and for mechanical thrombectomy, it is up to 24 hours in selected cases,” he added.
However, the National Stroke Registry indicated that only about 36.3 percent of patients arrive within 4.5 hours from symptoms onset. Overall, patients take an average of 7.2 hours to reach the hospital, which causes a lot of delay in treatment initiation. While patients treated with IV thrombolysis in the first 90 minutes are far more likely to walk independently, every 15-minute delay reduces the chance of functional independence by 4-5 percent. Therefore, recognising the signs and symptoms of a stroke based on the BE FAST acronym, and seeking urgent medical care, can make the difference between full recovery and long-term disability for the patient, said Hoo.
He added that treating a stroke requires multidisciplinary team effort between emergency physicians, first responders, vascular neurologists, neurointerventional surgeons and radiologists, imaging teams and other departments, to ensure prompt diagnosis and treatment.
At the hospital
If a stroke is suspected, the stroke protocol is activated, provided the patient has arrived within the treatment window, i.e., about 4.5 hours from the onset of symptoms, said Datuk Dr Alzamani Mohammed Idrose, Consultant Emergency Physician and Head, Emergency Department, Hospital Kuala Lumpur.
Once the stroke protocol is activated, the emergency doctor will quickly take the patient’s history, check vital signs, run the necessary blood tests, and arrange urgent brain imaging, which may include a computed tomography (CT) brain scan, CT perfusion, or CT angiogram, depending on the hospital’s available services. “Imaging can help determine whether the stroke is due to bleeding or blockage, and whether the patient is suitable for further treatment,” he explained.
The team will also assess the patient using the NIH Stroke Scale, which helps determine the severity of the stroke and whether the patient meets the criteria for clot-busting medication, he said. The NIH Stroke Scale is a structured scoring system that evaluates stroke severity from 0 (normal) to 42 (severe), to guide treatment and prognosis. [https://tinyurl.com/595vnhpn]
“We will also check for any contraindications, for example, a history of bleeding, recent surgery, or other risk factors that may make the patient unsuitable for clot-busting treatments. Once we have this information, we liaise with the neurology team, who will make the final decision on whether the patient can receive the treatment. The medication is then given to the patient according to protocol, and the patient will be closely monitored,” he said.
Once stabilised, patients are admitted to the ward where their progress is monitored. Some patients recover quite quickly, while others may take longer and require neurorehabilitation before discharge.
It is important to note that if a patient arrives late, such as the day after symptom onset, the stroke protocol is not activated because the treatment window has passed. In these cases, the patient is not eligible for thrombolytic treatment. Instead, they will receive supportive treatment and ongoing stroke management to aid their recovery, he said.